MEDICARE: KRISTA JELLE NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LN0005X	Critical Care Neonatal Nurse Practitioner	163769	WI

General Provider Information

NPI Number	:	1912559451
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTA JELLE NP

Provider Business Mailing Address
First Line	:	13111 N PORT WASHINGTON RD
Second Line	:
City	:	MEQUON
State	:	WI
Zip	:	53097-2416
Country	:	US
Telephone Number	:	262-243-7408
Fax Number	:

Provider Business Practice Location Address
First Line	:	3864 MAPLE GROVE DR APT 103
Second Line	:
City	:	MADISON
State	:	WI
Zip	:	53719-1824
Country	:	US
Telephone Number	:	608-206-0524
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/15/2019
Last Update Date	:	05/26/2021

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